Best and Promising Practices in LGBT Cultural Competence Trainingliz margolies, LCSW, National LGBT Cancer Network,

liz.margolies@gmail.comDaniel Bruner, JD, MPP, Whitman-Walker Health,

dbruner@whitman-walker.org

GLMA’s 37th Annual Conference on LGBT HealthNew Orleans, LA, September 11-14, 2019

Conflict of Interest DisclosuresDaniel Bruner: Gilead Sciences is a sponsor of the National LGBTQ Cultural Competency Summit discussed in this presentation. Whitman-Walker Health also has received funding from Gilead Sciences and ViiVHealthcare for a Mobile Outreach Retention and Engagement project, focusing on patients who have fallen out of care or who encounter significant barriers to engagement in care. Whitman-Walker participates in drug trials with a number of pharmaceutical companies. ViiV, Gilead and Janssen are financial supporters of Whitman-Walker’s Walk to End HIV.

Liz Margolies: Apart from the Gilead sponsorship of the National LGBTQ Cultural Competency Summit, no conflicts to disclose.

Goals of This PresentationWe hope to assist participants to:1. Develop and implement more efficient and effective LGBT

cultural competence training of health care providers and students.

2. More effectively address intersections of sexual orientation and gender identity with race, ethnicity, and other differences among LGBT patients.

3. Design trainings that help doctors, nurses and other health professionals become more effective communicators with patients and improve patient-centered care.

• Addressing the needs of LGBT people with cancer and those at risk by

• EDUCATING the LGBT community about our increased cancer risks and the importance of screening/early detection

• TRAINING healthcare providers to offer more safe, welcoming and culturally competent care to their LGBT patients

• ADVOCATING for LGBT inclusion in national cancer organizations, research and the media

• Based in NYC and Providence

National LGBT Cancer Network

Federally Qualified Health Center in Washington, DC, with a special mission to the LGBTQ community and to people living with HIV.

Outpatient medical, behavioral health, legal and community health services.

20,700 patients in 2018. Whitman-Walker staff and volunteers conduct numerous

trainings for medical students, residents, mental health and substance abuse treatment professionals, social service providers, elder and youth service providers and lawyers.

Whitman-Walker Health

Discrimination and stigma

Lack of access to care

UNEDUCATED PROVIDERS

LGBTQ Health Disparities are Caused by Multiple Factors

Lack of Provider Education in Treating LGBT Patients Medical School = 5 hours Nursing School = 2 hours

Provider Bias Both medical and nursing students express a

preference for treating cisgender and heterosexual patients Early exposure to LGBT patients linked to better attitudes

One Example of the Consequences ER study

Challenges With Providers

.

Growing availability Lacking generally agreed-upon standards Lacking generally agreed-upon measures of

success Cultural competency or cultural humility?

Cultural Competence Training

In the summer of 2018, we conducted a review of 39 published studies/evaluations of LGBTQ cultural competency trainings of health care and social service providers and staff.

What Does The Literature To Date Indicate On The Efficacy of LGBTQ Cultural Competence Trainings?

Wide range of audiences (medical and nursing students, mental health professionals, medical residents, ER personnel, nursing home and senior center staff, pediatricians, other medical specialties)

Wide range of training formats (brief and somewhat longer single sessions; half- to full-day sessions; multi-session courses) and methods (webinar, live lecture, video, interactive exercises, case studies).

Focus ranged from general LGBTQ to lesbian, gay and bisexual persons to transgender and gender nonconforming persons to LGBTQ elders to LGBTQ youth.

What Does The Literature To Date Indicate On The Efficacy of LGBTQ Cultural Competence Trainings?

Most studies have attempted to measure short-term impacts on provider/participant Knowledge, Attitudes, Skills and Behavioral Intentions.

Most have relied on provider/participant self-reporting (usually pre- and post-training questionnaires; occasionally post-training follow-up interviews or tests).

Measurement of actual impacts on patient experiences present formidable methodological challenges.

What Does The Literature To Date Indicate On The Efficacy of LGBTQ Cultural Competence Trainings?

The published studies generally show at least some improvements in knowledge, attitudes and self-reported behavioral intentions at the conclusion of training. Studies that followed up with trainees at a later date (e.g, 30, 60 or 90 days, or six months) often found that improvements tended to diminish with time, underscoring the need for follow-up training or a more intensive approach than a one-time session.

What Does The Literature To Date Indicate On The Efficacy of LGBTQ Cultural Competence Trainings?

Some studies specifically of LGBTQ-focused trainings have found that participants tended to respond more favorably to trainings that involved multiple exposures to the content as compared to a one-time session of short duration; that offered opportunities for interaction with trainers and fellow participants; that included presentations by or discussions with LGBT-identified individuals; and that offered opportunities for clinical exposure to LGBT patients.

What Does The Literature To Date Indicate On The Efficacy of LGBTQ Cultural Competence Trainings?

Studies of racial and ethnic-focused cultural competence trainings of health care providers, and of CME more generally, have concluded that trainings that utilize mixed methods –written materials, web-based materials and use of video, live presentations, case studies and role plays – tend to be the most effective.

Some studies of CME also have concluded that small-group trainings tend to foster more engagement and more favorable reactions by participants, and that trainings seem to have a greater impact when they are conducted for with providers of a single discipline, such as a training specifically for primary care physicians.

What Does The Literature To Date Indicate On The Efficacy of LGBTQ Cultural Competence Trainings?

History Goals – Reaching an expert consensus in the absence

of peer-reviewed evidence Steps in the process Where we are now How you can contribute

Best And Promising Practices For LGBTQ Cultural Competence Trainings Of Healthcare And Social Service

Providers And Staff

Madina Agenor, ScD, MPH Harvard School of Public HealthIgnatius Bau, JD Health policy consultant, San FranciscoLauren Beach, JD, PhD Northwestern University School of MedicineMarkus Bidell, PhD Hunter College and City University of New York Graduate CenterMandi Chapman, MA George Washington University Cancer CenterScott Cook, PhD University of Chicago School of MedicineLawrence R. Deyton, MD, MSPH George Washington University School of MedicineKristen Eckstrand, MD, PhD University of Pittsburgh Medical School Michelle Eliason, PhD San Francisco State University School of Nursing Thomas Freese, PhD UCLA Integrated Substance Abuse Programs;

Center of Excellence on Young MSMTari Hanneman, MPA Human Rights CampaignCecilia Hardacker, MSN, RN, CNL Howard Brown HealthJoAnne Keatley, MSW UCSF Center for Excellence in Transgender HealthAlex Keuroghlian, MD, MPH Fenway Institute and Harvard Medical SchoolFrederick Kron, MD U-Michigan and U-Virginia Medical SchoolsD Magrini Whitman-Walker HealthLiz Margolies, LCSW National LGBT Cancer NetworkAsa Radix, MD, MPH Callen-Lorde Community Health CenterBamby Salcedo TransLatin@ CoalitionBarbara Warren, PsyD Mount Sinai Health System;

Icahn School of Medicine at Mount Sinai

Summit Participants – October 2018

Recommendations circulated to more than 200 educators, providers, researchers and patient advocates throughout the U.S. – with special effort to reach persons working in the South, Midwest and (Non-Coastal) West, and providers, researchers and advocates working with communities of color.

Survey Monkey platform for comments: https://www.surveymonkey.com/r/NBWJD59

Preliminary RecommendationsOut For Community Review

General Principles Prepare for a Training: Know Your Audience Content for Cultural Competence Trainings Employ Multiple Methods of Delivery Use Trainers Effectively Recommended Resources Other Comments You Would Like to Share

Preliminary RecommendationsOut For Community Review

1. As a foundation, emphasize the diversity of LGBTQ people, recognize the challenges of living at the intersection of multiple identities, and the advance the goal of racial equity.

2. Address organizational and structural determinants of health, as well as individual provider knowledge, attitudes, skills and behavior.

3. Apply principles of adult learning theory.4. Apply principles of transformational learning theory.

Preliminary Recommendations: General Principles

1. Trainings should be developed with the specific audience in mind.

2. When possible, conduct a pre-training assessment.

Preliminary Recommendations: Prepare for a Training – Know Your Audience

1. While trainings will differ, the goals will be information, awareness, self awareness, and development of skills.

2. Center provider-patient encounters on individual patients to avoid stereotypes.

3. Include topics of: terminology, disparities and stigma, standards of care, disparities by subpopulation, intersectionality, communications skills, Implicit bias, asking SOGI questions, how barriers to care impact health.

4. Trainings should address institutional barriers and emphasize welcoming environments.

Preliminary Recommendations: Content for Cultural Competence Trainings

1. If possible, multiple shorter sessions are more effective.2. A mixture of training methods is preferred.3. Multimedia and immersive technologies are effective.4. Case studies work better than abstract presentation of

concepts.5. Relevant personal LGBTQ stories are well-received.6. Include activities that offer a safe space for participants

to examine themselves.

Preliminary Recommendations: Employ Multiple Methods for Delivery

1. Multiple trainers often are more effective than a single trainer.2. Audiences benefit from a diversity of trainers.3. Trainers need opportunities for personal development.4. Qualities of good trainers include familiarity with subjects,

experience, good communication skills, awareness of their own limitations.

5. Rather than establishing a certification system, work with existing orgs that offer continuing education credits.

6. When using community members/patients, consider fair compensation.

Preliminary Recommendations: Using Trainers Effectively

A list of other organizations that have developed cultural competence training curricula that can be used as models or starting points.

Preliminary Recommendations: Recommended Resources

1. Are there large gaps that we did not address?

2. What are your concerns about developing national standards, If any?

3. How, if at all, will these be useful in your work and workplace?

What Do You Think?

https://www.surveymonkey.com/r/NBWJD59

Please Send Us Your Comments!